By Counterforce Health Team in Rezlidhia (olutasidenib) —

The Complete Requirements Checklist to Get Rezlidhia (Olutasidenib) Covered by Aetna CVS Health in Florida

Answer Box: Quick Path to Approval

Rezlidhia (olutasidenib) requires prior authorization from Aetna CVS Health in Florida. To get approved: (1) Confirm your IDH1 mutation test results are documented, (2) gather records of failed prior AML therapies, and (3) have your hematologist/oncologist submit the PA request via Aetna's provider portal with complete clinical documentation. Standard approval takes 30-45 days; expedited reviews are available for urgent cases. If denied, you have 180 days to appeal internally and 4 months for external review in Florida.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Track
  9. Common Denial Prevention Tips
  10. Appeals Process in Florida
  11. Printable One-Page Checklist

Who Should Use This Checklist

This guide is designed for Florida patients diagnosed with relapsed or refractory acute myeloid leukemia (AML) with an IDH1 mutation, their caregivers, and healthcare teams seeking Aetna CVS Health coverage for Rezlidhia (olutasidenib).

Use this checklist if:

  • You have an Aetna plan administered through CVS Health
  • Your oncologist has recommended Rezlidhia for IDH1-mutated AML
  • You've received a denial or want to prevent one
  • You're preparing for a prior authorization submission

Expected outcome: Following this checklist improves your chances of first-time approval and reduces delays that could impact your treatment timeline.

Member & Plan Basics

Coverage Verification

Before starting, confirm these basics:

✓ Active Aetna Coverage

  • Verify your plan is active and includes prescription drug benefits
  • Note if you have an HMO, PPO, or Medicare Advantage plan
  • Check your member ID and group number

✓ Deductible Status

  • Specialty drugs like Rezlidhia may apply to your deductible
  • High-deductible plans may require significant out-of-pocket costs initially
  • Contact member services at 1-888-632-3862 to verify your current deductible status

✓ Prior Authorization Requirement Rezlidhia appears on Aetna's 2024 precertification list, confirming PA is required for coverage.

Clinical Criteria Requirements

FDA-Approved Indication

✓ Confirmed AML Diagnosis

  • Patient must be 18 years or older
  • Documented relapsed or refractory acute myeloid leukemia
  • Disease status must be clearly noted in medical records

✓ IDH1 Mutation Testing

  • FDA-approved test results confirming susceptible IDH1 mutation
  • Test must be performed at a CLIA-certified laboratory
  • Include the specific mutation identified in documentation

✓ Specialist Prescriber

  • Prescription must come from a hematologist or oncologist
  • Provider credentials should be clearly documented
  • Board certification information may strengthen the request

Step Therapy Documentation

✓ Prior Treatment History Document all previous AML therapies attempted, including:

  • Specific agents used (chemotherapy regimens)
  • Treatment dates and duration
  • Reason for discontinuation (progression, toxicity, intolerance)
  • Response to each therapy

✓ Current Disease Status

  • Recent imaging or bone marrow biopsy results
  • Current performance status
  • Treatment goals and prognosis

Coding & Billing Requirements

ICD-10 Codes for AML

Use the most specific code matching your diagnosis:

Code Description When to Use
C92.02 Acute myeloblastic leukemia, in relapse Most common for relapsed AML
C92.52 Acute myelomonocytic leukemia, in relapse For AMML subtype
C92.A2 AML with multilineage dysplasia, in relapse For MDS-related AML

✓ Code Selection

  • Match the ICD-10 code to your pathology report
  • Ensure "relapsed" or "refractory" status is documented
  • Incorrect coding is a frequent cause of denials

Drug Coding Information

✓ NDC Number: 71332-005-01 (150 mg capsules) ✓ No J-Code: Rezlidhia is oral and billed through pharmacy benefits, not medical benefits ✓ Dosing: Standard dose is 150 mg twice daily (300 mg total daily)

Documentation Packet Checklist

Required Clinical Documents

✓ Provider Letter of Medical Necessity Include these elements:

  • Patient demographics and insurance information
  • Complete AML diagnosis with staging
  • IDH1 mutation test results with lab name and date
  • Detailed prior treatment history
  • Clinical rationale for Rezlidhia
  • Planned monitoring for differentiation syndrome
  • Provider credentials and contact information

✓ Laboratory Reports

  • IDH1 mutation testing results
  • Recent complete blood count
  • Comprehensive metabolic panel
  • Liver function tests (baseline for monitoring)

✓ Treatment History Documentation

  • Discharge summaries from prior treatments
  • Oncology clinic notes documenting disease progression
  • Imaging reports showing treatment response/failure

✓ Supporting Guidelines Reference current treatment guidelines:

Submission Process

Aetna CVS Health Submission Methods

✓ Online Portal (Preferred)

  • Use Availity provider portal for fastest processing
  • Upload all documents in PDF format
  • Ensure file sizes meet portal requirements

✓ Fax Submission

  • Prior authorization fax: (verify with current Aetna forms)
  • Include cover sheet with member information
  • Confirm fax transmission receipt

✓ Required Forms

Timing Considerations

✓ Submit Early

  • Submit requests at least 2 weeks before intended start date
  • Allow extra time during holidays or high-volume periods
  • Consider expedited review if treatment delay poses health risks

Specialty Pharmacy Requirements

✓ Network Pharmacy Verification

  • Confirm your preferred specialty pharmacy is in Aetna's network
  • CVS Specialty Pharmacy is typically preferred for Aetna members
  • Verify pharmacy can handle specialty drug shipments to your location

✓ Transfer Process

  • Coordinate with your oncology team for prescription transfer
  • Ensure all prior authorization approvals transfer with prescription
  • Verify insurance information is updated at specialty pharmacy

✓ Shipment Coordination

  • Arrange delivery timing with your treatment schedule
  • Ensure someone is available to receive temperature-sensitive medications
  • Confirm storage requirements with pharmacy

After Submission: What to Track

Documentation & Follow-up

✓ Confirmation Numbers

  • Record submission confirmation number
  • Keep copies of all submitted documents
  • Note submission date and method

✓ Status Checking Schedule

  • Check status after 5-7 business days
  • Follow up weekly until determination
  • Document all communications with Aetna

✓ Decision Timeline

  • Standard decisions: 30-45 days
  • Expedited reviews: 72 hours
  • Additional information requests may extend timeline

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Missing IDH1 Mutation Documentation
    • Problem: Submitting without clear mutation test results
    • Solution: Include complete lab report with specific mutation identified
  2. Incomplete Prior Treatment History
    • Problem: Vague references to "prior chemotherapy"
    • Solution: Detail each regimen with dates, duration, and outcomes
  3. Wrong Prescriber Type
    • Problem: Primary care or non-oncology prescriber
    • Solution: Ensure hematologist/oncologist submits the request
  4. Exceeding Quantity Limits
    • Problem: Requesting more than approved dosing
    • Solution: Stick to FDA-approved 150 mg twice daily dosing
  5. Incomplete Forms
    • Problem: Missing required fields or signatures
    • Solution: Use current forms and complete all sections

Appeals Process in Florida

If your initial request is denied, Florida residents have specific appeal rights under state law.

Internal Appeal Process

✓ Timeline: 180 days from denial notice to file appeal ✓ Decision Timeline: 7 days for prescription drug appeals (72 hours if expedited) ✓ Submission: Use Aetna's appeal forms or call 1-866-235-5660

External Review Rights

If Aetna upholds the denial after internal appeal: ✓ Timeline: 4 months from final adverse determination ✓ Process: Request external review through Florida Department of Financial Services ✓ Cost: No charge to consumer; decision is binding on Aetna

From our advocates: We've seen cases where initial denials were overturned simply by including the complete IDH1 mutation report that was missing from the first submission. Always double-check that your molecular testing documentation clearly shows the specific mutation that makes you eligible for Rezlidhia.

State Resources for Help

  • Florida Department of Financial Services: 1-877-693-5236
  • Insurance Consumer Helpline: Available for assistance with appeals process
  • Online complaint filing: Available through DFS website

Printable One-Page Checklist

Before You Start

  • Active Aetna CVS Health coverage confirmed
  • Member ID and group number available
  • Hematologist/oncologist identified as prescriber

Clinical Requirements

  • AML diagnosis documented (relapsed/refractory)
  • IDH1 mutation test results available
  • Prior treatment history compiled
  • Current disease status documented

Documentation Package

  • Provider letter of medical necessity
  • IDH1 mutation lab report
  • Prior treatment records
  • Current lab results (CBC, CMP, LFTs)
  • Completed PA form

Submission

  • Submitted via Availity portal or fax
  • Confirmation number recorded
  • All documents included
  • Follow-up schedule established

After Submission

  • Status checked weekly
  • Additional information requests addressed promptly
  • Appeal rights understood if denied

About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Rezlidhia. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that address payer-specific requirements, helping patients access life-saving treatments faster.

If you need additional support navigating the Aetna CVS Health prior authorization process or appealing a denial, Counterforce Health provides specialized assistance for oncology medications and complex prior authorization requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider and insurance company for specific guidance about your situation. Appeal rights and timelines may vary by plan type and state regulations.

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